Is there justification for levels of polyp competency? Dr Roland Valori Gloucestershire Hospitals United Kingdom

Transcription

1 Is there justification for levels of polyp competency? Dr Roland Valori Gloucestershire Hospitals United Kingdom

2 What exactly will be required? Defining levels of polypectomy competency in terms of complexity/time/risk Having training programmes with competency assessments at each level Being clear about who is allowed to do what a badge or license for each level Clear pathways for patients with informed and shared decision making Evaluating these steps Ultimately we want to achieve excellent outcomes and ensure that decisions are not constrained by what is on offer

3 P rocedure Date Friday 14 September :49 th Friday 14 September :49 Site 1, Rectum Site 2, Proximal ascending colon Unsedated 54 year old female with IBS Would you remove this polyp now? If not would you refer to a surgeon? Site 2, Proximal ascending colon

4 Operative data from US From 2000 through 2014, there were 1,230,458 surgeries for benign colorectal polyps and colorectal cancer in the United States. Among those surgeries, 25% were performed for benign colorectal polyps. Rates of surgery/100,000 population Benign polyps Colorectal cancer Peery AF, et al. Increasing Rates of Surgery for Patients With Non malignant Colorectal Polyps in the United States. Gastroenterology Apr;154(5): )

5 Unwarranted variation in polypectomy Variation in practice Recognition Decision making Excision technique Tattooing Retrieval rates Surveillance decisions Unwarranted consequences Incomplete resection Post colonoscopy CRC Complications Unnecessary operations Waste resources Waste patient time Death

6 Approaches to improving quality Define, measure and review metrics and deal with poor performance OR Put processes and structures in place before you start to have the best chance of getting it right first time OR BOTH

7 Polypectomy has been an afterthought We have Metrics for safety and +/- for quality A competency framework (DOPyS) BUT Polypectomy training has lagged behind teaching intubation and detection skills

8 European Guideline (2010) for QA of CRC screening and diagnosis: To help in the planning of location of endoscopic services for screening, the following four levels of competency are proposed Level Type of polyp Setting/endoscopist 1 Lesions <10mm in diameter FS screening 2 Polypoid and sessile lesions <25mm providing there is good access. 3 Smaller flat lesions (<20mm) that are suitable for endoscopic therapy, larger sessile and polypoid lesions and smaller lesions with more difficult access 4 Large flat lesions or other challenging polypoid lesions that might also be treated with surgery All colonoscopists FIT screening positive colonoscopy Regionally based colonoscopists Valori R, et al. Endoscopy 2012;44:SE88-SE105

9 SMSA polypectomy scoring system SMSA Score Size <1cm cm cm cm 7 >4cm 9 Morphology Pedunculated 1 Sessile 2 Flat 3 Site Left 1 Right 2 Access Easy 1 Difficult 3 Level Level Level Level Site 4 1, Rectum >12 SMSA = 14 Gupta S, et al. Frontline Gastroenterology 2013;4:

10 SMSA polypectomy scoring 220 polyps >2cm in 220 patients 37% level 2 and 3, 63% level 4 SMSA related to complications and clearance but not cancer The SMSA assessment tool enables lesions to be effectively stratified for prognostic information, training, level of expertise required, and reimbursement tariffs. Longcroft-Wheaton et al. Dis Colon Rectum 2013; 56:

11 Distribution of SMSA scores, n=2305ibutisa scores, n=2305 Sidhu M, et al. The size, morphology, site, and access score predicts critical outcomes of endoscopic mucosal resection in the colon. Endoscopy Jan 25. SMSA % SMSA % SMSA 2 9.9% SMSA number of patients/lesions

12 SMSA 2 Median procedure duration 10 min Likelihood of Success 98.7% Delayed bleeding 1.7% Recurrence 5.4% Late recurrence SMSA 3 Median procedure duration 15 min Likelihood of Success 97.4% Delayed bleeding 5.0% Recurrence 10.4% Late recurrence SMSA 4 Median procedure duration 30 min Likelihood of Success 94.0% Delayed bleeding 7.8% Recurrence 23.7% Late recurrence Sidhu M, et al. The size, morphology, site, and access score predicts critical outcomes of endoscopic mucosal resection in the colon. Endoscopy Jan 25.

13 Conclusions In prospective data derived from over 2000 patients undergoing EMR for large LSL the SMSA polyp score reliably predicted Success of EMR Adverse events during and after EMR Risk of recurrence after EMR The components of the SMSA polyp score can easily be obtained from an adequate referral letter/report Sidhu M, et al. The size, morphology, site, and access score predicts critical outcomes of endoscopic mucosal resection in the colon. Endoscopy Jan 25.

14 Implications of using SMSA List planning Correct lesion for correct practitioner (avoid incomplete excision) Accurate timing per lesion Predicting adverse events Enhanced informed consent Risk of complications can be prospectively discussed with patients and plans made Post procedural care plans can reflect the risk of the procedure for example patients with a high risk of delayed bleeding Modification of anticoagulation etc. Risk of recurrence may dictate surveillance intervals Allows prospective estimation of procedural costs Training Right lesion allocated to correct stage of training

15 What is the justification? Hierarchy of issues What does the patient want? Good experience, safe, high quality, informed choice Health system Best possible outcome at low cost Endoscopist Job satisfaction, payment, avoid complaints and litigation

16 What exactly will be required? Defining levels of polypectomy competency in terms of complexity/time/risk Having training programmes with competency assessments at each level Being clear about who is allowed to do what a badge or license for each level Clear pathways for patients with unbiased and informed shared decision making Evaluating these steps Evaluate performance of polypectomy Ultimately we want to achieve excellent outcomes and ensure that decisions are not constrained by what is on offer